Restorative Dentistry

Endodontics is concerned with the cause, diagnosis, prevention, and treatment of diseases of the dental pulp and periradicular tissues. The successful outcome of endodontic treatment requires thorough disinfection of the root canals followed by the precise placement of a well compacted root filling to within 2mm of the apex of the tooth, and a well- sealed restoration to prevent further infection or fracture. It is a complex technical process.

Pulpal and periadicular disease is very common and the Hospital can only accept a limited number of patients for specialist treatment or training purposes and the referral criteria are set out below.

• Previous endodontics with complications (e.g. blockage, perforation, ledging, carrier-based obturation system, separated instrument)
• Canals not radiographically visible (*) and an unsuccessful attempt made to locate them
• Canals dividing middle/apical third (*)
• Possible root fracture(s)
• Post or fractured post removal after unsuccessful attempt at post removal with ultrasonic energy
• Root canal curvature >30° (*)
• Difficulty achieving anaesthesia (*)
• Confusing/complex/atypical signs of odontogenic pain
• Internal/external resorption or significant apical resorption (*)
• Open apices (*)
• Abnormal tooth/root form (*) (e.g. fusion/ dens in dente/ taurodontism)
• Endodontic treatment as part of complex Restorative treatment planning
• Assessment for periradicular surgery
• Dento-alveolar trauma
• Request for second opinion on tooth retention where the tooth is strategically important and functional

• Any tooth requiring de novo root canal treatment, unless there are challenges (see above, marked with *)
• Previous endodontic treatment without procedural complications (marked by an asterisk above)
• Complex treatment of teeth in poorly maintained mouths
• Re-treatment of second or third molars, unless there is a discernible need for their preservation – this may include the tooth being a key abutment or to avoid extractions in patients who would present a surgical risk
• Patients who will not tolerate rubber dam or prolonged mouth opening

Periodontology is concerned with the diagnosis and treatment of diseases and conditions of the soft and hard supporting tissues of the teeth, and the management of oral manifestations of systemic diseases.

Some periodontal conditions, including where there is an association with systemic disease (e.g. Diabetes), require treatment within secondary care and some require tertiary care (e.g. HIV, Epidermolysis Bullosa, drug-induced gingival overgrowths, vesiculobullous/erosive gingival diseases, certain syndromes involving the mouth).

Control of other modifiable risk factors, particularly smoking, should have been instigated by the referring clinician. Primary care including root surface debridement must have been performed in practice but the patient continues to suffer from significant periodontitis. Significant periodontal disease would be a score of code 4 in all sextants on the BPE screen, although the following criteria would also merit acceptance:

• Any patient with desquamative gingivitis, regardless of BPE score
• Patients with gingival overgrowth (drug induced or otherwise)
• Patients with localised gingival recession that may require periodontal plastic surgery
• Adolescents aged <16yrs with attachment loss, regardless of BPE score
• Patients with recurrent NUG, regardless of BPE score
• BPE score of 4 in any sextant and one or more of the following:-
• Patients under the age of 35
• A concurrent medical factor that is directly affecting the periodontal tissues
• Grade 2 or 3 furcation disease or Grade 3 mobility
• Surgery involving periodontal tissues
• Surgical procedures involving periodontal tissue augmentation and/or bone removal
• Surgical procedures associated with osseo-integrated implants placed within the NHS

• Patients with a poor level of home care or motivation towards their own role in disease management
• BPE score below 4 in any sextant(s)
• Under exceptional circumstances, more localised disease may be appropriate for care

Referring practitioners will be responsible for long term supportive periodontal therapy (‘maintenance’) upon patients being referred back to the practice environment. Alternatively, patients who do not maintain good levels of oral hygiene will be returned to the referring GDP for palliative periodontal care.

Prosthetic Dentistry is concerned with the restoration and maintenance of oral function by the replacement of missing teeth and structures primarily by the use of removable and fixed prosthodontics. Such treatment is normally provided within the primary dental service but some complex situations require specialist management within a secondary care setting. Some obturator treatment such as replacement prosthesis and cleft palate dentures are also undertaken.

The removable prosthetics clinic is not able to provide treatment of a routine nature unless there is an educational need at the time of consultation. For example, patients requiring complete or partial dentures may be accepted onto undergraduate clinics, with the patient's consent.

Following assessment, if it is felt that the provision of treatment is outwith the scope of undergraduates but is not specialist care then it is expected that the patient will return to their practitioner. This will be for any recommended treatment or for discussion of the feasible treatment options.

For partially dentate cases a contemporaneous set of study casts brought by the patient (not sent with the referral proforma) to their consultation would support advice on the appropriate design that can then be taken back to the referrer.

Where it is clear that all efforts have been made by the referring practitioner to address the patient’s issues, or in the case of re-referral, where the treatment plan has been accurately followed, patients may be accepted for treatment within the capacity of the service.

• Removable prosthesis/prostheses for priority patient groups
• Functional problems with removable prosthesis/prostheses in patients with severe anatomical challenges (from surgical intervention, maxillofacial trauma or exceptional patterns of resorption)
• Functional problems with removable prosthesis/prostheses in patients with medical problems affecting prosthodontic procedures (for example, neuromuscular disorders)

The Fixed Prosthodontic Service is mainly a diagnostic, treatment planning and advice service. Patients can be referred for assessment of tooth wear, assessment prior to reorganisation of the occlusion, cosmetic issues, treatment planning etc. but it is expected that the patient will return to their practitioner for treatment. This will be for any recommended treatment or for discussion of the feasible treatment options. Unless there is an educational need, only patients requiring fixed prosthesis/prostheses from the priority patient groups will be accepted for treatment.

The criteria for implant placement on the NHS are very strict. The following categories are considered high priority for implant treatment on the NHS:

• Patients with developmental conditions resulting in deformed and/or missing teeth
• Patients who have lost teeth due to trauma
• Patients who have undergone ablative surgery for head and neck cancer
• Patients with extra-oral defects
• Patients who are edentulous in one or both jaws
• Patients with severe denture intolerance
• Patients with aggressive periodontitis
• Patients requiring implant-borne orthodontic anchorage

Patients must belong to one of these categories and satisfy the other criteria set below.

General Factors
Exclusion criteria:  Smoking, Uncontrolled Diabetes Mellitus, intravenous bisphosphonate therapy, severe psychoses/neuroses.

Dental Factors
Inclusion criteria:  good periodontal health, remaining dentition sound
Exclusion criteria:  poor oral hygiene, untreated periodontal disease, ongoing caries or where the prognosis of any natural teeth adjacent to the proposed implant sites is judged to be uncertain in the short, medium or long term.

Insurance Claims
Possible exclusion criteria:  Patients pursuing damages via legal/insurance system are encouraged to pursue care within the private sector, so as to reserve NHS resources for patients with no financial help.

Maintenance
Monitoring and maintenance will be delivered within the general dental service

Clinical Indications
The criteria (above) must be met and the patient should fall into one of the following groups:

• Mild, Moderate and Severe cases of Hypodontia will be considered. Implants may not be the first line treatment in the replacement of congenitally absent teeth both distal to and including premolars
• Cleft Palate/Cleft Lip and Palate cases may benefit from dental implant therapy.
• Ectopic teeth that have not responded
• Congenitally malformed teeth (for example, amelogenesis imperfecta, dens invaginatus) may be replaced by dental implant therapy if prosthodontic /endodontic approaches are not successful.
• Replacement of teeth following traumatic loss of one or more teeth may be with dental implant therapy. Cases of historical trauma will be given equal consideration.
• Implants to support restorations after ablative surgery for head and neck cancer.

Edentulousness
The fact that a patient dislikes the thought of, or is unwilling to wear dentures, or would like to have their existing denture replaced by an implant-retained prosthesis does not in itself justify implant-based rehabilitation.

Implant-retained restorations will only be provided once an optimised conventional denture has been constructed by an experienced clinician. This denture will help to assess patient tolerance of the denture and serve as the first step (radiographic template/surgical guide) if implants are to be provided.

• Maxillary Edentulousness: Implant-retained overdenture (not fixed bridgework) may be considered in specific clinical circumstances (for example, intact and healthy mandibular teeth opposing an atrophic maxillary ridge).
• Mandibular Edentulousness: Implant-retained overdenture (not fixed bridgework) may be considered if the conventional denture is not tolerated and painful.
• Severe Denture Intolerance. An assessment of the amount of base extension the patient is able to tolerate should be made in the first instance either by a conventional denture or a transitional base plate constructed by an experienced clinician. A full arch bridge will not be provided.
   

Generalised Aggressive Periodontal Disease
Consideration may be given to replacing teeth lost to aggressive periodontal disease in the absence of smoking.

Inclusion criteria:  teeth lost to aggressive periodontal disease, good oral hygiene and if the periodontal disease is being successfully managed.
Exclusion criteria:  poor oral hygiene, ongoing periodontal disease, ongoing caries, or where the prognosis of any natural teeth adjacent to the proposed implant sites is judged to be uncertain in the short, medium or long term.

This summary is based on the Guideline for Selecting Appropriate Patients to Receive Dental Implants: Priorities for the NHS (RCS England 2012).